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Thursday, July 07, 2011

Public Comment Period for Proposed Diagnostic Criteria Extended Through July 15

ARLINGTON, Va. (July 7, 2011) – The American Psychiatric Association’s diagnostic criteria for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) propose a significant reformulation in how personality disorders are identified and assessed. The change integrates disorder types with pathological personality traits and, most importantly, levels of impairment in what is known as “personality functioning.”

With its multidimensional framework, this hybrid model is very different from the way personality disorders are presented as rigid behavioral categories in the current manual. The goal of the new criteria is to maximize their utility to clinicians and benefit to patients.

DSM is the standard classification used by mental health and other health professionals for diagnostic and research purposes. The manual’s next edition, representing the latest scientific understanding of the etiology, characteristics and relationships of mental disorders, will be published in 2013. Release of DSM-5 will culminate more than a decade of rigorous work involving hundreds of experts from the United States and abroad.

The new draft criteria for personality disorders are currently being evaluated through field trials in real-world clinical settings across the country. Public comment also is invited on the proposed revisions to these and other diagnostic criteria. Submissions will now be accepted through July 15. All criteria are available for review on www.dsm5.org.

As recommended by the DSM-5 Personality and Personality Disorders Work Group, 10 categories will be reduced to six specific personality disorder types (antisocial, avoidant, borderline, narcissistic, obsessive/compulsive and schizotypal). But for a diagnosis within these descriptive classifications, several conditions must be met.

Critically, a person must have significant impairment in the two areas of personality functioning – self and interpersonal. Self is defined as how patients view themselves as well as how they identify and pursue goals in life. Interpersonal is defined as whether an individual is able to understand other people’s perspectives and form close relationships. The scale by which these will be judged ranges from mild to extreme.

In addition, the work group determined that pathological personality traits must be present in at least one of five broad areas – such as whether a person is antagonistic versus able to get along with others, or impulsive versus able to think through possible consequences of action.

“The importance of personality functioning and personality traits is the major innovation here,” said Andrew Skodol, M.D., the work group’s chair and a research professor of psychiatry at the University of Arizona College of Medicine. “In the past, we viewed personality disorders as binary. You either had one or you didn’t. But we now understand that personality pathology is a matter of degree.”

Noted Robert Krueger, Ph.D., a member of the work group and a professor of psychology at the University of Minnesota, “Our proposed criteria get away from the idea that personality pathology is just a group of disorders. We’re instead defining it as a much broader characteristic.”

Underlying the work group’s recommendations are longitudinal studies and other clinical research since the early 1990s that have revealed the shortcomings of the current behavior-based criteria. Because behavior can be intermittent and changeable over time, the criteria can hinder an accurate diagnosis and even impede treatment.

By contrast, impairments in personality functioning and pathological personality traits tend to be more stable over time and consistent regardless of the situation. Both stability and consistency would be required under the revisions to the diagnostic criteria.

Over the next year, the DSM-5 Task Force and its work groups will continue refining the categories and specifics of all disorders to be included in the next edition. The current public comment period will play into their deliberations. As with the first public review last year, when the APA received more than 8,000 written responses from clinicians, researchers and family and patient advocates, every comment will be considered. As of mid-June, nearly 1,800 additional responses had been submitted.

In the meantime, the first round of field trials continues at nearly a dozen larger academic and clinical centers; almost 3,900 mental health professionals in individual practice and smaller settings also will participate before the trials conclude. Another public comment period on the criteria will then follow.

The DSM-5 diagnostic criteria will be determined by 2012 and submitted to the APA’s Board of Trustees for review and approval.

The American Psychiatric Association is a national medical specialty society whose more than 36,000 physician members specialize in the diagnosis, treatment, prevention and research of mental illnesses, including substance use disorders. Visit the APA at www.psych.org and www.healthyminds.org

I'm not gonna lie - I just don't understand the point of this. To access services? Personality disorder - just has never made sense to me. Personality disorder: a label we use to describe people we don't like in our society, for whatever reason. Everything else is a diagnosis - not a definition of a human being. This is - it seems cruel.

I guess we will just have to wait and see how this works. The reduced number of categories sounds like the new classification might be more restrictive than the existing one. This would be a move in the wrong direction, I think. On the other hand, acknowledging increased variety in the severity of symptoms suggests more subtlety in diagnosis, which I think is a positive move.

With respect to Rob's question, a "pathological personality trait" would be an inflexible and maladaptive way of perceiving and relating to reality. For example, someone who finds themselves to be lonely and distressed by a lack of close relationships but who cannot exhibit pro-social behaviors or acknowledge those behaviors in others.

With regard to Carrie's statement, I think that too often personality diagnoses are used simply to call people names. This is a misuse of the diagnoses. Their misuse does not mean that they do not have a legitimate use as well. I treat many patients with personality disorders who find comfort in knowing that the problems they deal with are shared by others and who are relieved to know that there are treatments available to reduce their distress and improve their lives. Misuse can surely be cruel, but proper use can be extremely compassionate.

If I were a sensible person, I'd read the new criteria before commenting on them. Oh well.

With regard to personality disorders, I frankly have little use for DSM (go ahead, burn me at the stake) for anything other than filling out paperwork and providing a common vocabulary when consulting with other professionals. Since my tyro years it has held no real place in my clinical work.

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Okay. I've read it now, and read with particular attention the PDF article called Brief Rationale and Status of the Development of a Trait Dimensional Diagnostic System for Personality Disorder in DSM-5. I am less flippant, but still confused as to how the new definitions would be more useful to me and other practitioners or beneficial to our patients than the old.

I suppose I travel in the wrong circles. Academic medicine is not in the least interesting to me. At the same time, I truly appreciate the immense thought and work that went into these new criteria and some of the ideas proposed are interesting (the "hybrid dimensional-categorical model" for instance). Maybe I'm just an old dog and resistance to new tricks.

wv = actie. Must see where that fits on the Levels of Personality Functioning scale

I share KT's perceptions and opinions. The DSM is used for research, but also for insurers to pay/not pay and for legal uses. It is important, but I suspect the vast majority of clinicians use it sparingly except for paperwork purposes. That may be because there are a number of criteria, axes, experiences and frameworks that let us make our decisions about treatment. The DSM is a guide, but it is not determinative.

It may seem like it is a disadvantage that our practice can be flexible, but it is really an advantage to our patients. Human beings are exceedingly complex! To have no structure is to be lost, but to have it be too rigid is also an error.

Inflexibility and maladaptiveness?not good traits, but they are pathological only in the sense that a liar is pathological, that is to say metaphoricallyWv - calikon. Greek letter and all-purpose cleanser

@The Alienist - I'd be curious to know what those same patients say about care from non-psychiatric medical providers. I think the diagnosis seen on a chart sets up a certain dynamic - we can lie to ourselves that it does not, but it does in so many ways/cases - before the interaction even occurs. I work in a setting where I have high interaction with women who are opioid/benzo dependent due to history of drug addiction and have just delivered babies. I take care of the babies - but frankly I'd rather not read "borderline" as a diagnosis in the chart. I work really well with this population, but to read that is to set up certain anxieties in me prematurely that may or may not be even warranted. I do not ever treat them differently, but it definitely affects the interaction before it even begins by making me worried/stressed over how it will go, if nothing else. (Color me anxious.) Then again, "This baby has NAS (Neonatal Abstinence Syndrome - for Dinah ;)" can also affect the interaction before it begins in a variety of ways - so maybe listing personality disorder really doesn't matter in the grand scheme of things.

To flip this, I've got an anaphylactic allergy to haldol - it was used as an inpatient treatment for severe migraine. I tell any medical provider that I have that allergy and I get this uneasy look. I preemptively explain it constantly because it bothers me that people jump to conclusions.

I agree that knowing a diagnosis can be helpful in so many ways, but it should never be presumed that it does not have implications that can also hurt. What are we if not our personalities? To say they are somehow defective is pretty harsh. But to learn to work within and with certain strengths and weaknesses is an important thing.

"For example, someone who finds themselves to be lonely and distressed by a lack of close relationships but who cannot exhibit pro-social behaviors or acknowledge those behaviors in others."

I'm wondering how this would be differentiated from higher-functioning autism spectrum disorders. The standard advice for social problems assumed to be the result of a personality disorder seems to be not to over-analyze and to assume that if you don't know why someone seems angry, it probably has nothing to do with you. I'm sure you can imagine the degree to which that particular technique will backfire for anybody who has real trouble recognizing and understanding social signals and nonverbal communication. (Especially in girls, who so rarely conform to the male-centric stereotypes about what a person with Asperger's is like.)

"For example, someone who finds themselves to be lonely and distressed by a lack of close relationships but who cannot exhibit pro-social behaviors or acknowledge those behaviors in others."

I'm wondering how this would be differentiated from higher-functioning autism spectrum disorders. The standard advice for social problems assumed to be the result of a personality disorder seems to be not to over-analyze and to assume that if you don't know why someone seems angry, it probably has nothing to do with you. I'm sure you can imagine the degree to which that particular technique will backfire for anybody who has real trouble recognizing and understanding social signals and nonverbal communication. (Especially in girls, who so rarely conform to the male-centric stereotypes about what a person with Asperger's is like.)

Maggie, I think one of the things with Autism spectrum disorders is that they are almost always detected earlier in the child's life than a personality disorder (and aren't many personality disorders caused at least in part by childhood experiences? I'm not doubting genetics in some of it especially for antisocial disorder where maybe they weren't born with some gene necessary for empathy or something).

My daughter wasn't diagnosed until age 6, but we knew by age 2-1/2 to 3 that she was a little different. It just needed time for us to realize "different enough to need assessment for . . . whatever it is." She's VERY high functioning; cases "lower" on the spectrum would likely be more obvious, sooner. And of course in hindsight, upon all the developmental questions during the diagnosis process, we could see issues, especially sensory ones, going back to birth. It sure explained ALOT. I need to blog about the whole process sometime, of getting her diagnosed; it's an emotional subject for me though.

I agree with Carrie. Why do we use the word personality? It seems to be almost an attack on a person, and who they are (not what they do). PDs seem to me to be learned behaviour from severe childhood mistreatment. Surely this is a cognitive and behavioural set that is learned and can be unlearned? How does this then differ from what CBT appears to be targeting? One is just long term vs intermittent.

When I diagnose one of my patients with a personality disorder, I am careful to explain what the diagnosis means. The different diagnoses mean that patients have characteristic strengths and weaknesses that affect how they perceive the world and interact with others.

In an ideal world, these diagnoses would be commonly understood and would increase our understanding of the needs and behaviors of others. Unfortunately, too often they are simply used to stigmatize.

For example, I know that my borderline patients have problems with social attachment. Sometimes they seem too "sticky." Other times, they seem too rejecting. Once I recognize that they have borderline personality disorder, I can better understand their difficulty in regulating closeness and understand their conflict between losing their identity in relationships with others and wanting to have sustained, caring relationships. Such an understanding enables me to be more compassionate and empathic in dealing with them.

Also, with regard to Rob's post. A personality that is inflexible and maladaptive is no less pathological than a heart rate that lacks normal variability or cortisol levels that lack diurnal variation.